T H E M E : M E N ’ S H E A L T H

UNIT NO. 4 A P P R O A C H T O U R I N A R Y S Y M P T O M S I N M E N Dr Lim Kok Bin, Dr Michael Wong Yuet Chen

PREVIEW ii) polyuria (due to uncontrolled diabetes mellitus This unit covers the definition, pathophysiology and diagnostic (DM), diabetes insipidus, on diuretics) approach to lower urinary tract symptoms in male. It also iii) small bladder capacity [infection, tumour, stone, showcases some common pitfalls faced by primary health care bladder outlet obstruction (BOO), neurogenic providers. bladder, foreign body] Recorded in terms of how many hours between voiding (usual 2 hours) OBJECTIVES At the end of this unit, the course participants should be able b) Nocturia – awake at night to urinate to describe the following: Same pathophysiology as in frequency. 1. Definition of lower urinary tract symptoms 1 – 2 times per night is inconsequential if patients drink 2. Pathophysiology of lower urinary tract symptoms a few cups of coffee before bed 3. Differential diagnosis of lower urinary tract symptoms c) Urgency – sensation to urinate immediately if an accident 4. Assessment of lower urinary tract symptoms is to be avoided. Often accompanies infection, BOO or 5. Common pitfalls. neurogenic bladder d) – burning or painful sensation on urination, 1. URINARY SYMPTOMS IN MEN felt in the . Eg in (UTI) e) Strangury – a subtype of dysuria in which intense Three main groups of symptoms: discomfort accompanies frequent voiding of small amount of . 1) Obstructive a) slow/weak stream _ decrease force _ b) hesitancy in voiding prolonged interval necessary to 3) Incontinence initiate voiding c) straining _ need to increase intra abdominal pressure to a) Urge incontinence initiate voiding Result of involuntary rise in intravesical pressure d) decreased calibre _ narrowing of stream secondary to detrusor contraction which overcomes e) split stream – bifurcation or splaying of stream, implies outlet resistance, i.e bladder instability possible eg, local causes: UTI, , tumour (carcinoma f) terminal dribbling – prolonged dribbling of urine after in situ / CIS), , foreign body, loss of completion of micturition cortical inhibition of voiding reflex in strokes, dementia g) sense of residual urine – sensation of incomplete or Parkinsonism emptying of bladder h) intermittency _ interrupted stream. eg. Benign prostatic hyperplasia (BPH), urethral stricture, cancer of prostate, acute prostatitis, bladder neck contracture, meatal stenosis, detrusor sphincter dyssynergia, stone, foreign body.

2) Irritative a) Frequency – need to urinate more often than usual. It can be due to: i) polydipsia (high fluid intake)

LIM KOK BIN, Registrar, Department of Urology, Singapore General Hospital MICHAEL WONG YUET CHEN, Senior Consultant, Department of Urology, Singapore General Hospital A P P R O A C H T O U R I N A R Y S Y M P T O M S I N M E N

Table 1. 3. DIAGNOSIS Functional classification a) Failure to store History 1. because of bladder (i.e detrusor hyperreflexia, local irritants) K Determine onset and duration of symptoms 2. because of outlet (i.e incompetent sphincter mechanism) K Quantify symptoms eg how many times do you wake b) Failure to empty up at night to urine? What is the interval between 1. because of bladder (i.e detrusor areflexia) 2. because of outlet (i.e sphincter dysynergia, BPH, stricture) successive urination during daytime? K Associated symptoms eg frequency, urgency, dysuria implies UTI (cystitis, , prostatitis) b) K History of perineal or pelvic trauma (stricture), prior This is due to failure to empty bladder rather than instrumentation (stricture, bladder neck contracture), inability to store urine. Eg. BOO (BPH, strictures), venereal diseases (stricture) detrusor weakness (DM, anticholinergic medications) K History of spinal injury or combination of both K History of stone disease K Other medical conditions eg DM, MS, stroke, c) This is due to the sudden increase in intra abdominal Parkinson’s disease, psychiatric disorders pressure (laughing, straining etc) resulting in elevated K Medications eg alpha agonists, anticholinergics, anti psychotics etc. bladder pressure causing urine leakage. It is frequently after radical prostatectomy for carcinoma of prostate or rarely after transurethral resection of prostate (TURP) Physical examination K Abdominal examination especially to exclude any d) Enuresis palpable bladder, ballotable renal mass or inguinal Involuntary urination and bed wetting during sleep. hernia Usually implies overflow incontinence in adult male. K Examine the penis for any phimosis, paraphimosis or meatal stenosis K Rectal examination to assess the prostate size and 2. PATHOPHYSIOLOGY consistency as well as anal tone K If neurological cause suspected, proceed to do full Neurophysiology of Voiding neurological assessment. 1. Act of micturition is a reflex function under voluntary control 2. Coordination of micturition reflex (detrusor contraction 4. ASSESSMENT with sphincter relaxation) is controlled by brainstem (pontine) micturition centre via long spinal pathways (loop 1. IPSS (international prostate symptoms score) II) to sacral cord (S2, S3, S4) Classified as mild (0 – 7), moderate (8 – 19) or severe (20 – 3. This in turn under voluntary control of suprapontine higher 35) functions via loop I. 2. Urinalysis +/- urine cultures Pyuria – infection, stone, foreign body Hence, three possible scenarios: Sugar – need to exclude DM 1) Detrusor hyperreflexia with coordinated external sphincter Hamaturia – malignancy, stone relaxation due to: 3. Voiding charts a) suprapontine lesion involving loop I (stroke, Parkinson’s Patient will chart down amount of fluid intake and amount disease, tumour) of urination every time per day for at least 3 days b) non neurologic local causes (infection, BOO, tumour, 4. Serum electrolytes and creatinine stone, foreign body) Indicator of renal function 2) Detrusor hyperreflexia with external sphincter dyssynergia due 5. Fasting blood sugar to suprasacral spinal lesions involving loop II [tumour, To exclude DM multiple sclerosis (MS), myelodysplasia, spinal arterio- 6. Prostate specific antigen venous malformation (AVM)] Prostate organ specific but not cancer specific 3) Detrusor areflexia due to: 7. Uroflowmetry and postvoid residual urine a) interruption of sacral reflex arcs (DM neuropathy, MS, Peak urine flow rate – objective documentation of severity herniated disc, spinal cord tumour) of obstruction. Useful indicator of response to treatment b) myogenic cause (prolonged retention) Postvoid residual urine is single most useful information c) also during initial spinal shock after suprasacral spinal – categorised patients into failure to store or failure to cord injury. empty A P P R O A C H T O U R I N A R Y S Y M P T O M S I N M E N

8. Urodynamics e) An elderly man who complained of stress incontinence Include uroflowmetry, cystometry, urethral pressure and nocturnal enuresis may be in urinary retention profilometry and electromyography f) High index of suspicion if a man with no other medical 9. Imaging conditions came with urinary retention – may be spinal An intravenous urogram is indicated in patients with cord problem. haematuria, persistent infections or suspected bladder tumour An ultrasound scan of the bladder can detect any significant RECOMMENDED READING 1. PM Hanno, SB Malkowicz, AJ Wein (eds). Clinical Manual of intravesical prostatic protrusion that suggests BPH Urology, third edition. McGraw – Hill International Edition. 10.Cystoscopy 2. RM Weiss, NJR George, PH O’Reilly (eds). Comprehensive If associated haematuria, persistent infection or suspected Urology. Mosby. tumour.

5. COMMON PITFALLS LEARNING POINTS a) Beware of persistent UTI or irritative symptoms despite O Lower urinary tract symptoms are the summation of multiple adequate treatment – may be CIS or muscle invasive urinary symptoms, characterized by the interplay between bladder function or outlet obstruction bladder tumour O Multiple differential diagnoses are possible and a firm diagnosis, b) Nocturia may be an indicator of insomnia and not based on careful history and physical examination, supported organic urological problems by urinalysis and voiding chart, could be established in most c) Look out for polydipsia as a cause of urinary symptoms cases – do voiding charts O There are common pitfalls that one should be aware of, such d) Frequency and nocturia may be first presentation of as CIS in patients with irritative symptoms, DM in patients with polyuria and insomnia in patients complaining of nocturia. underlying DM